WO1999020261A2 - Use of antigunal agents for the topial treatment of fungus-induced mucositis - Google Patents

Use of antigunal agents for the topial treatment of fungus-induced mucositis Download PDF

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Publication number
WO1999020261A2
WO1999020261A2 PCT/US1998/022403 US9822403W WO9920261A2 WO 1999020261 A2 WO1999020261 A2 WO 1999020261A2 US 9822403 W US9822403 W US 9822403W WO 9920261 A2 WO9920261 A2 WO 9920261A2
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WO
WIPO (PCT)
Prior art keywords
formulation
mammal
fungus
antifungal agent
induced
Prior art date
Application number
PCT/US1998/022403
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English (en)
French (fr)
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WO1999020261A3 (en
Inventor
Jens Ponikau
Original Assignee
Jens Ponikau
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Priority to KR1020007004368A priority Critical patent/KR20010031363A/ko
Priority to EEP200000253A priority patent/EE200000253A/xx
Application filed by Jens Ponikau filed Critical Jens Ponikau
Priority to ES98955065T priority patent/ES2292210T3/es
Priority to AU11959/99A priority patent/AU1195999A/en
Priority to IL13577498A priority patent/IL135774A0/xx
Priority to JP2000516659A priority patent/JP2001520188A/ja
Priority to EP98955065A priority patent/EP1024814B1/en
Priority to SK573-2000A priority patent/SK5732000A3/sk
Priority to DE69838338T priority patent/DE69838338T2/de
Priority to HU0004170A priority patent/HUP0004170A3/hu
Priority to APAP/P/2000/001805A priority patent/AP2000001805A0/en
Priority to CA2308201A priority patent/CA2308201C/en
Priority to BR9814615-7A priority patent/BR9814615A/pt
Priority to EA200000439A priority patent/EA200000439A1/ru
Priority to DK98955065T priority patent/DK1024814T3/da
Publication of WO1999020261A2 publication Critical patent/WO1999020261A2/en
Publication of WO1999020261A3 publication Critical patent/WO1999020261A3/en
Priority to NO20002069A priority patent/NO325714B1/no
Priority to IL135774A priority patent/IL135774A/en
Priority to IS5463A priority patent/IS5463A/is
Priority to BG104371A priority patent/BG104371A/xx
Priority to HK01100853A priority patent/HK1029935A1/xx

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Definitions

  • the invention relates to methods and materials involved in the treatment and prevention of non-invasive fungus-induced inflammation of mucosal tissue as well as asthma symptoms.
  • Mucositis the inflammation of mucosal tissue
  • allergenitis allergic fungal sinusitis
  • AFS chronic rhinosinusitis cases requiring surgery because of nasal obstruction caused by polyp formation.
  • AFS is diagnosed by the presence of inspissated mucus in the nasal-paranasal cavities. Typically, this mucus contains clumps or sheets of necrotic eosinophils, Charcot-Leyden crystals, and non-invasive fungal hyphae.
  • patients with AFS typically have a history of nasal- paranasal polyposis and may have undergone multiple surgeries. Inflammation can affect all nasal-paranasal cavities, but also can be asymmetric involving only one side.
  • Computed topography (CT) scans of patients with AFS have a characteristic appearance and often reveal bone erosion in adjacent structures. Indeed, destruction of bones adjacent to the sinuses and nasal areas ranging from 19 percent to 80 percent has been reported. Although fungal organisms seem to be the causative agent of AFS, successful treatment remains lacking.
  • AFS patients as well as most chronic rhinosinusitis patients receive surgical treatment with or without steroid therapy. Surgery helps clear the nasal-paranasal cavities when obstructed by polyps and steroid therapy helps control infl-ammatory responses that seem to be causing tissue and bone destruction.
  • patients treated with surgery alone almost always experience recurrent rhinosinusitis symptoms and additional polyp growth.
  • the present invention relates generally to methods and materials for treating and preventing non-invasive fungus-induced mucositis.
  • mucositis as used herein means an inflammation, as opposed to an infection, of a mucus membrane.
  • This invention is based on the discovery that the condition known as AFS can be treated successfully by using an antifungal agent in an amount, at a frequency, and for a duration effective to reduce inflammation caused by the presence of fungal organisms within nasal-paranasal mucus.
  • this invention is based on the discovery that using an antifungal agent in an amount, at a frequency, and for a duration effective to maintain a reduced level of fungal organisms within nasal-paranasal mucus can prevent AFS symptoms.
  • the invention involves administering an antifungal agent to a mammal such that the antifungal agent contacts the mammal's mucus and reduces the presence of fungal organisms in mucus.
  • an antifungal agent is particularly advantageous to a patient when compared to other currently available medical approaches to AFS such as surgical treatments and steroid therapies. Such medical approaches can have side effects, can be costly, and may be associated with patient discomfort.
  • This invention is also based on the discovery that most, if not all, chronic rhinosinusitis conditions have a fungal etiology and that most, if not all, cases of chronic rhinosinusitis can be treated by using an antifungal agent in an amount, at a frequency, and for a duration effective to reduce the presence of fungal organisms within nasal-paranasal mucus.
  • using an antifungal agent in an amount, at a frequency, and for a duration effective to maintain a reduced level of fungal organisms within nasal-paranasal mucus can prevent chronic rhinosinusitis symptoms.
  • non-invasive fungus-induced rhinosinusitis includes AFS as well as any other nasal-paranasal mucositis condition having a non-invasive fungal etiology.
  • Treating and preventing non-invasive fungus-induced rhinosinusitis, whether diagnosed as AFS or any other rhinosinusitis condition having a non- invasive fungal etiology, by using an antifungal agent circumvents the need for surgical treatments and steroid therapies that cause significant pain and suffering to the patient.
  • the use of antifungal agents to treat and prevent non- invasive fungus-induced rhinosinusitis actually directs treatment against the etiological agent (i.e., fungus), unlike surgical treatments, steroid therapies, and antibacterial treatments.
  • chronic refers to afflictions present for at least three months. It is to be understood that afflictions that are treated as described herein and become asymptomatic can be classified as chronic. Thus, chronic afflictions can be symptomatic or asymptomatic.
  • This invention is also based on another, equally significant, discovery that chronic asthma symptoms can be treated and prevented successfully by using an antifungal agent in an amount, at a frequency, and for a duration effective to reduce the presence of fungal organisms within airway mucus. It is also apparent from the present discoveries that antifungal agents can be administered directly to the lung airways for the treatment of chronic asthma. Again, these discoveries are contrary to the current understanding of chronic asthma and have far-reaching clinical implications. Taken together, these significant breakthroughs can potentially allow large populations to experience happier, healthier, and more productive daily lives.
  • the invention provides methods and materials for treating and preventing a wide variety of mucoinflammatory diseases by using an antifungal agent.
  • the use of an antifungal agent is a safe and highly effective treatment approach that involves mucoadministering an antifungal agent in an amount, at a frequency, and for a duration effective to reduce, prevent, or eliminate a non- invasive fungus-induced mucositis.
  • the term "mucoadministration" as used herein refers to any type of administration that places an administered agent in contact with mucus.
  • This invention also provides specific antifungal formulations that can be applied to the various parts of a mammal that contain mucus.
  • the invention provides medical devices that can be used to apply antifungal formulations.
  • the invention provides improved methods and materials for collecting and culturing fungal organisms from mucus samples. These culturing techniques can be used to monitor the number of fungal species within mucus during a particular antifungal treatment regimen.
  • these fungus collecting and culturing methods and materials are useful for identifying the genotype and phenotype of specific fungal organisms that cause non-invasive fungus-induced mucositis.
  • the identification and characterization of non-invasive fungal organisms found in a particular individual's mucus can assist clinicians in determining proper treatment and prophylactic approaches. For example, this information can help determine the specific antifungal agent, amount, mode of administration, and number of applications to be used as well as possible combinatorial therapies that may include other medications and procedures such as steroids, antibacterial agents, and surgery.
  • the invention features a method for treating a mammal (e.g., human) having non-invasive fungus-induced rhinosinusitis.
  • This method involves directly mucoadministering to at least a portion of the mammal's nasal-paranasal anatomy a formulation in an amount, at a frequency, and for a duration effective to reduce or eliminate non-invasive fungus-induced rhinosinusitis.
  • This formulation contains an antifungal agent or a plurality of antifungal agents and can be in a solid, liquid, or aerosol form (e.g., a powder, crystalline substance, gel, paste, ointment, salve, cream, solution, suspension, partial liquid, spray, nebulae, mist, atomized vapor, aerosol, and tincture).
  • the formulation can be in a form suitable for self-mucoadministration by a human.
  • the formulation can contain a pharmaceutically acceptable aqueous vehicle (e.g., saline and water).
  • a liquid form of the formulation can contain about 0.00001 percent to about 20 percent of an antifungal agent as determined by antifungal agent weight per aqueous vehicle volume.
  • the formulation can contain about 0.01 ng to about 1000 mg of an antifungal agent (e.g., amphotericin B) per liter in some embodiments of the invention, or about 1 ng to about 500 mg of an antifungal agent per liter in other embodiments of the invention, or about 100 mg of an antifungal agent per liter in still other embodiments of the invention.
  • an effective amount of these aqueous formulations can be about 0.01 mL to about 1 L of formulation per nostril in some embodiments of the invention, or about 5 mL to about 100 mL of formulation per nostril in other embodiments of the invention, or about 40 mL of formulation per nostril in still other embodiments of the invention.
  • an effective amount of a formulation can be about 0.01 ng to about 1000 mg of an antifungal agent per kg of body weight of the mammal in some embodiments of the invention or about 1 ng to about 500 mg of an antifungal agent per kg of body weight of the mammal in other embodiments of the invention.
  • the effective amount of a formulation can change or remain the same during an effective duration.
  • the effective frequency of direct mucoadministration can be from about four times a day to about once every other week in some embodiments of the invention, or from about twice a day to about once a week in other embodiments of the invention, or about twice a day in still other embodiments of the invention.
  • the effective frequency of direct mucoadministration can be greater than once a day, or greater than once a week.
  • the effective duration can be greater than about 7, 14, 30, 60, or 90 days.
  • the mammal can be atopic or nonatopic and can be immunocompetent or immunocompromised.
  • the non-invasive fungus-induced rhinosinusitis can be characterized by polyp formation or polypoid change.
  • the non-invasive fungus-induced rhinosinusitis also can be a chronic condition.
  • Mucoadministration can be an irrigation of at least a portion of the nasal-paranasal anatomy with a liquid form of the formulation.
  • the mucoadministration can involve applying an aerosol form of the formulation to at least a portion of the nasal-paranasal anatomy.
  • An antifungal agent can be in a solid, liquid, or aerosol form.
  • an antifungal agent can be a polyene macrolide, tetraene macrolide, pentaenic macrolide, fluorinated pyrimidine, imidazole, azole, triazole, halogenated phenolic ether, thiocarbamate, allylamine, sterol inhibitor, and an agent that interpolates fungal cell wall components.
  • Such antifungal agents include amphotericin B, flucytosine, ketoconazole, miconazole, itraconazole, fluconazole, griseofulvin, clotrimazole, econazole, terconazole, butoconazole, oxiconazole, sulconazole, saperconazole, voriconazole, ciclopirox ol.amine, haloprogin, tolnaftate, naftifine, terbinafine hydrochloride, morpholines, nystatin, natamycin, butenafme, undecylenic acid, Whitefield's ointment, propionic acid, and caprylic acid.
  • the formulation can contain, without limitation, a pharmaceutically acceptable aqueous vehicle, pharmaceutically acceptable solid vehicle, steroid, mucolytic agent, antibacterial agent, anti-inflammatory agent, immunosuppressant, dilator, vaso-constrictor, decongestant, leukotriene inhibitor, anti-cholinergic, anti- histamine, therapeutic compound, and combinations thereof.
  • the method can also involve administering a second formulation that contains, without limitation, an antifungal agent, antibacterial agent, steroid, mucolytic agent, anti-inflammatory agent, immunosuppressant, dilator, vaso-constrictor, decongestant, leukotriene inhibitor, anti-cholinergic, anti- histamine, therapeutic compound, or combination thereof.
  • the method can involve an additional step after the direct mucoadministration. This additional step can be a prophylactic mucoadministration of a prophylactic formulation to the mammal in .an .amount, at a frequency, and for a duration effective to prevent non- invasive fungus-induced rhinosinusitis.
  • This prophylactic formulation also contains an antifungal agent and can be in a solid, liquid, or aerosol form (e.g., powder, crystalline substance, gel, paste, ointment, salve, cream, solution, suspension, partial liquid, spray, nebulae, mist, atomized vapor, aerosol, tincture, pill, capsule, tablet, and gelcap).
  • an antifungal agent e.g., powder, crystalline substance, gel, paste, ointment, salve, cream, solution, suspension, partial liquid, spray, nebulae, mist, atomized vapor, aerosol, tincture, pill, capsule, tablet, and gelcap.
  • the prophylactic mucoadministration can be a direct or indirect mucoadministration.
  • the prophylactic mucoadministration can be an irrigation of at least a portion of the nasal-paranasal anatomy with a liquid form of the prophylactic formulation, an application of an aerosol form of the prophylactic formulation to at least a portion of the nasal-paranasal anatomy, or an oral administration of the prophylactic formulation to the mammal in the form of a solid or liquid.
  • methods for prophylactically treating a mammal at risk for developing non-invasive fungus-induced rhinosinusitis may utilize a formulation in which the antifungal agent is about 0.00001 percent to about 20 percent by weight or volume of a formulation, and so forth.
  • the invention features a method for prophylactically treating a mammal at risk for developing non-invasive fungus- induced rhinosinusitis. This method involves mucoadministering to the mammal a formulation in an amount, at a frequency, and for a duration effective to prevent non-invasive fungus-induced rhinosinusitis.
  • This formulation contains an antifungal agent.
  • Another embodiment of the invention features a method for treating a mammal having non-invasive fungus-induced rhinosinusitis.
  • This method involves the steps of identifying (e.g., diagnosing) the mammal, and directly mucoadministering a formulation to at least a portion of the nasal-paranasal anatomy of the mammal in an amount, at a frequency, and for a duration effective to reduce or eliminate non-invasive fungus-induced rhinosinusitis.
  • This formulation contains an antifungal agent.
  • Another embodiment of the invention features a method for prophylactically treating a mammal at risk for developing non-invasive fungus- induced rhinosinusitis.
  • This method involves the steps of identifying the mammal (e.g., diagnosing), and mucoadministering a formulation to at least a portion of the nasal-paranasal anatomy of the mammal in an amount, at a frequency, and for a duration effective to prevent non-invasive fungus-induced rhinosinusitis.
  • This formulation contains an antifungal agent.
  • the invention features a method for treating a mammal having asthma.
  • This method involves directly mucoadministering to at least a portion of the airways (e.g., nasal-paranasal airways and lung airways) of the mammal a formulation in an amount, at a frequency, and for a duration effective to reduce or eliminate asthma symptoms.
  • This formulation contains an antifungal agent.
  • the direct mucoadministration can be the irrigation of the nasal-paranasal anatomy of the mammal with a liquid form of the formulation.
  • the direct mucoadministration can be the inhalation of the formulation through the mammal's mouth or nose.
  • the method can involve an additional step after the direct mucoadministration. This additional step can be the prophylactic mucoadministration of a prophylactic formulation to the mammal in an amount, at a frequency, and for a duration effective to prevent asthma symptoms.
  • This prophylactic formulation also contains an antifungal agent.
  • the invention features a method for prophylactically treating a mammal at risk for developing asthma.
  • This method involves mucoadministering to at least a portion of the airways (e.g., nasal- paranasal airways and lung airways) of the mammal a formulation in an amount, at a frequency, and for a duration effective to prevent asthma symptoms.
  • This formulation contains an antifungal agent.
  • Another embodiment of the invention features a method for treating a mammal having asthma.
  • This method involves the steps of identifying (e.g., diagnosing) the mammal, and directly mucoadministering a formulation to at least a portion of the airways (e.g., nasal-paranasal airways and lung airways) of the mammal in an amount, at a frequency, and for a duration effective to reduce or eliminate asthma symptoms.
  • This formulation contains an antifungal agent.
  • Another embodiment of the invention features a method for prophylactically treating a mammal at risk for developing asthma.
  • This method involves the steps of identifying the mammal (e.g., diagnosing), and mucoadministering a formulation to at least a portion of the airways (e.g., nasal- paranasal airways and lung airways) of the mammal in an amount, at a frequency, and for a duration effective to prevent asthma symptoms.
  • This formulation contains an antifungal agent.
  • the invention features a method for treating a mammal having non-invasive fungus-induced intestinal mucositis (e.g., chronic colitis and Crohn's disease).
  • This method involves mucoadministering to the mammal a formulation in an amount, at a frequency, and for a duration effective to reduce or eliminate non-invasive fungus-induced intestinal mucositis symptoms.
  • This formulation contains an antifungal agent and can be in the form of a regulated release capsule (e.g., pH or time regulated release capsule).
  • the mucoadministration can be the oral application of the formulation within the digestive tract of the mammal.
  • the mucoadministration can be the application of the formulation within the digestive tract of the mammal by way of an enema.
  • the invention features a method for prophylactically treating a mammal at risk for developing non-invasive fungus- induced intestinal mucositis (e.g., chronic colitis and Crohn's disease).
  • This method involves mucoadministering to the mammal a formulation in an amount, at a frequency, and for a duration effective to prevent non-invasive fungus-induced intestinal mucositis symptoms.
  • This formulation contains an antifungal agent.
  • the invention features a method for treating a mammal having non-invasive fungus-induced otitis media.
  • This method involves mucoadministering to the mammal a formulation in an amount, at a frequency, and for a duration effective to reduce or eliminate non-invasive fungus-induced otitis media.
  • This formulation contains an antifungal agent.
  • the mucoadministration can be the application of the formulation within the middle ear of the mammal.
  • a liquid form of the formulation can be used to irrigate the middle ear if the tympanic membrane is elevated or not intact.
  • a formulation can be injected into the middle ear or a myringotomy can be used to penetrate the tympanic membrane.
  • myringotomy tubes can be used to bypass the tympanic membrane.
  • a formulation can be mucoadministered to the middle ear through the nose and eustachian tube.
  • the invention features a method for prophylactically treating a mammal at risk for developing non-invasive fungus- induced otitis media.
  • This method involves mucoadministering to the mammal a formulation in an amount, at a frequency, and for a duration effective to prevent non-invasive fungus-induced otitis media.
  • This formulation contains an antifungal agent.
  • the invention features an article of manufacture that contains packaging material (e.g., boxes, wrappings, vials, and other containers) and a formulation contained within the packaging material.
  • This formulation contains an antifungal agent.
  • the packaging material contains a label or package insert indicating that the formulation can be directly mucoadministered to at least a portion of the nasal-paranasal anatomy of a mammal having non-invasive fungus- induced rhinosinusitis in an amount, at a frequency, and for a duration effective to reduce or eliminate non-invasive fungus-induced rhinosinusitis.
  • the invention features an article of manufacture that contains packaging material and a formulation contained within the packaging material.
  • This formulation contains an antifungal agent and the packaging material contains a label or package insert indicating that the formulation can be mucoadministered to at least a portion of the nasal-paranasal anatomy of a mammal at risk for developing non-invasive fungus-induced rhinosinusitis in an amount, at a frequency, and for a duration effective to prevent non-invasive fungus-induced rhinosinusitis.
  • Another embodiment of the invention features an article of manufacture that contains packaging material and a formulation contained within the packaging material.
  • This formulation contains an antifungal agent.
  • the packaging material contains a label or package insert indicating that the formulation can be directly mucoadministered to at least a portion of the airways of a mammal having asthma in an amount, at a frequency, and for a duration effective to reduce or eliminate asthma symptoms.
  • Another embodiment of the invention features an article of manufacture that contains packaging material and a formulation contained within the packaging material.
  • This formulation contains an antifungal agent and the packaging material contains a label or package insert indicating that the formulation can be mucoadministered to at least a portion of the airways of a mammal at risk for developing asthma in an amount, at a frequency, and for a duration effective to prevent asthma symptoms.
  • Another embodiment of the invention features .an article of manufacture that contains packaging material and a formulation contained within the packaging material.
  • This formulation contains an antifungal agent.
  • the packaging material contains a label or package insert indicating that the formulation can be mucoadministered to a mammal having non-invasive fungus-induced intestinal mucositis in an amount, at a frequency, and for a duration effective to reduce or eliminate non-invasive fungus-induced intestinal mucositis symptoms.
  • Another embodiment of the invention features an article of manufacture that contains packaging material and a formulation contained within the packaging material.
  • This formulation contains an antifungal agent and the packaging material contains a label or package insert indicating that the formulation can be mucoadministered to a mammal at risk for developing non-invasive fungus-induced intestinal mucositis in an amount, at a frequency, and for a duration effective to prevent non-invasive fungus-induced intestinal mucositis symptoms.
  • Another embodiment of the invention features an article of manufacture that contains packaging material and a formulation contained within the packaging material.
  • This formulation contains an antifungal agent.
  • the packaging material contains a label or package insert indicating that the formulation can be mucoadministered to a mammal having non-invasive fungus-induced otitis media in an amount, at a frequency, and for a duration effective to reduce or eliminate non- invasive fungus-induced otitis media symptoms.
  • Another embodiment of the invention features an article of manufacture that contains packaging material and a formulation contained within the packaging material.
  • This formulation contains an antifungal agent and the packaging material contains a label or package insert indicating that the formulation can be mucoadministered to a mammal at risk for developing non-invasive fungus-induced otitis media in an amount, at a frequency, and for a duration effective to prevent non-invasive fungus-induced otitis media symptoms.
  • the invention features the use of an antifungal agent for the manufacture of a medicament for the treatment or prevention of non- invasive fungus-induced rhinosinusitis.
  • the invention features the use of an antifungal agent for the manufacture of a medicament for the treatment or prevention of asthma symptoms.
  • Another embodiment of the invention features the use of an antifungal agent for the manufacture of a medicament for the treatment or prevention of non- invasive fungus-induced intestinal mucositis.
  • Another embodiment of the invention features the use of an antifungal agent for the manufacture of a medicament for the treatment or prevention of non- invasive fungus-induced otitis media.
  • the invention features an antifungal formulation containing an antifungal agent, a flavoring, and water.
  • the water constitutes at least about 50 percent of the formulation.
  • the water can constitute at least about 55, 60, 65, 70, 75, 80, 85, 90, 95, or 99 percent of the formulation.
  • the invention features an antifungal formulation containing itraconazole and water.
  • the itraconazole is dissolved in the formulation at a concentration greater than about 25 ⁇ g per mL.
  • the itraconazole can be dissolved in the formulation at a concentration greater than about 30, 40, 50, 60, 70, 80, 90, 100, 110, 120, 130, 140, 150, 160, 170, or 180 ⁇ g per mL.
  • the water constitutes at least about 50 percent of the formulation.
  • the water can constitute at least about 55, 60, 65, 70, 75, 80, 85, 90, 95, or 99 percent of the formulation.
  • the formulation also can contain polyethylene glycol (e.g., PEG-200, PEG-400, PEG-800, etc.).
  • the formulation also can contain flavoring (e.g., peppermint oil, cherry flavoring, syrup, and the like).
  • the invention features an antifungal formulation containing itraconazole and water.
  • the itraconazole is suspended in the formulation at a concentration greater than about 25 ⁇ g per mL.
  • the itraconazole can be suspended in the formulation at a concentration greater than about 30, 40, 50, 60, 70, 80, 90, 100, 110, 120, 130, 140, 150, 160, 170, or 180 ⁇ g per mL.
  • the water constitutes at least about 50 percent of the formulation.
  • the water can constitute at least about 55, 60, 65, 70, 75, 80, 85, 90, 95, or 99 percent of the formulation.
  • the formulation also can contain polyethylene glycol (e.g., PEG-200, PEG-400, PEG-800, etc.).
  • the formulation also can contain flavoring (e.g., peppermint oil, cherry flavoring, syrup, and the like).
  • the invention features an antifungal formulation containing an antifungal agent, a flavoring, and water.
  • the water constitutes at least about 50 percent of the formulation.
  • the water can constitute at least about 55, 60, 65, 70, 75, 80, 85, 90, 95, or 99 percent of the formulation.
  • the antifungal agent can be amphotericin B, ketoconazole, saperconazole, voriconazole, flucytosine, miconazole, fluconazole, griseofulvin, clotrimazole, econazole, terconazole, butoconazole, oxiconazole, sulconazole, ciclopirox olamine, haloprogin, tolnaftate, naftifine, terbinafine hydrochloride, morpholines, nystatin, natamycin, butenafme, undecylenic acid, Whitefield's ointment, propionic acid, and caprylic acid.
  • the invention features a method of making an antifungal formulation.
  • the formulation contains itraconazole and water.
  • the itraconazole is dissolved in the formulation at a concentration greater than about 25 ⁇ g per mL.
  • the itraconazole can be dissolved in the formulation at a concentration greater than about 30, 40, 50, 60, 70, 80, 90, 100, 110, 120, 130, 140, 150, 160, 170, or 180 ⁇ g per mL.
  • the water constitutes at least about 50 percent of the formulation.
  • the water can constitute at least about 55, 60, 65, 70, 75, 80, 85, 90, 95, or 99 percent of the formulation.
  • the method includes adding the water to a stock solution containing the itraconazole.
  • the invention features a method for culturing fungus from a mammal's mucus.
  • the method includes (1) contacting the mucus with a mucolytic agent to reduce the viscosity of the mucus, (2) separating the fungus from the reduced- viscosity mucus, (3) contacting the separated fungus with fungus growth medium to form a fungus culture, and (4) incubating the fungus culture such that the separated fungus grows.
  • the invention features a method for obtaining a fungal antigen.
  • the method includes (1) contacting a mammal's mucus with a mucolytic agent to reduce the viscosity of the mucus, (2) separating fungus from the reduced- viscosity mucus, (3) contacting the separated fungus with fungus growth medium to form a fungus culture, (4) incubating the fungus culture such that the separated fungus grows, and (5) isolating the antigen from the cultured fungus.
  • the invention features a method for producing a fungus-specific antibody.
  • the method includes (1) contacting a mammal's mucus with a mucolytic agent to reduce the viscosity of the mucus, (2) separating fungus from the reduced-viscosity mucus, (3) contacting the separated fungus with fungus growth medium to form a fungus culture, (4) incubating the fungus culture such that the separated fungus grows, (5) isolating a fungal antigen from the cultured fungus, and (6) immunizing an animal with the fungal antigen to produce the antibody.
  • the invention features a nasal mucus collecting apparatus.
  • the apparatus contains a collection retainer, a collection tube, and a connecting portion.
  • the collection retainer is suitable for retaining mucus.
  • the collection tube extends from the collection retainer and defines a distal end and a lumen such that mucus can traverse the lumen from the distal end of the collection tube to the collection retainer.
  • the collection tube is generally flexible over at least a portion of the tube's length such that the collection tube can be selectively manipulated into a desired configuration by a practitioner during a collection procedure.
  • the collection tube further is generally malleable such that the collection tube generally retains the desired configuration until the practitioner manipulates the collection tube to conform to a different configuration.
  • the connecting portion extends from the collection retainer and defines a second lumen that communicates with the interior of the collection retainer.
  • the connecting portion is adapted to receive a vacuum source.
  • the apparatus can further contain a valve that adjusts the opening of the second lumen.
  • the collection retainer can be removable from the collection tube and the connection portion.
  • the invention features a pharmaceutical composition containing an antifungal agent.
  • the invention features a pharmaceutical composition containing an antifungal agent and an mucolytic agent.
  • Another embodiment features a pharmaceutical composition containing an antifungal agent and a steroid. Another embodiment features a pharmaceutical composition containing an antifungal agent and a decongestant.
  • Another embodiment features a pharmaceutical composition containing an antifungal agent and an antibiotic.
  • Another embodiment features a pharmaceutical composition containing an antifungal agent and an anti-inflammatory.
  • Another embodiment features a pharmaceutical composition containing an antifungal agent and an anti-histamine.
  • Another embodiment features a pharmaceutical composition containing an antifungal agent and an anti-cholinergic. Another embodiment features a pharmaceutical composition containing an antifungal agent and a leukotriene inhibitor.
  • the invention features a composition for treating an immune response to fungus in a mammal, characterized by an agent configured for direct mucoadministration to the mucus of the mammal and having antifungal means for eliminating or reducing the fungus below a threshold level wherein the fungus ceases to activate eosinophile migration to the affected area.
  • the invention features a pharmaceutical composition for treating a fungal related condition in the nasal-sinus anatomy, pulmonary anatomy, ear anatomy, or intestinal anatomy of a mammalian patient, said composition comprising an effective dose of an anti-fungal as described herein.
  • the invention features a pharmaceutical composition for treating a fungal related condition in the nasal-sinus anatomy, pulmonary anatomy, ear anatomy, or intestinal anatomy of a mammalian patient, said composition comprising an effective dose of an anti-fungal and at least one other agent or inhibitor as described herein.
  • the invention features a pharmaceutical composition for treating a fungal related condition in the nasal sinus anatomy, pulmonary anatomy, ear anatomy, or intestinal anatomy of a mammalian patient, said composition comprising an effective dose of an anti-fungal suitable for long term use within the nasal-sinus anatomy.
  • the invention features a medication for treating sinusitis, asthma, otitis media, or colitis of a patient, comprising a mucolytic agent; and an anti-fungal compound as described herein.
  • the invention features an irrigation medication for treating an inflamed nasal area, lung area, ear area, or intestinal area of a patient, the inflamed nasal area, lung area, ear area, or intestinal area being caused by the presence of a fungus, the medication comprising effective doses of an antifungal compound and a steroid as described herein.
  • the invention features an irrigation medication for treating an inflamed nasal area, lung area, ear area, or intestinal area of a patient, the inflamed nasal area, lung area, ear area, or intestinal area being caused by the presence of a fungus, the medication comprising effective doses of an antifungal compound and a mucolytic agent.
  • the invention features an irrigation medication for treating an inflamed nasal area, lung area, ear area, or intestinal area of a patient, the inflamed nasal area, lung area, ear area, or intestinal area being caused by the presence of a fungus, the medication comprising effective doses of a steroid and a mucolytic agent as described herein.
  • the invention features an irrigation medication for treating an inflamed nasal area, lung area, ear area, or intestinal area of a patient, the inflamed nasal area, lung area, ear area, or intestinal area being caused by the presence of a fungus, the medication comprising effective doses of an antifungal compound, a steroid, and a mucolytic agent as described herein.
  • the invention features an irrigation medication for treating an inflamed nasal area, lung area, ear area, or intestinal area of a patient, the inflamed nasal area, lung area, ear area, or intestinal area being caused by the presence of a fungus, the medication comprising an effective dose of at least one medicine selected from the group consisting of an antifungal compound, a steroid, a mucolytic agent, and any combination thereof as described herein.
  • Figure 1 is a CT scan of a patient with bilateral chronic rhinosinusitis.
  • Figure 2 is a CT scan of the patient of Figure 1, four months later, after treatment with antifungal irrigations.
  • Figure 3 is a diagram depicting a device for collecting mucus.
  • Figure 4 is a diagram depicting a device for collecting mucus.
  • the invention involves methods and materials for treating and preventing non-invasive fungus-induced mucositis. Specifically, the invention involves mucoadministering an antifungal agent in an amount, at a frequency, and for a duration effective to prevent, reduce, or eliminate chronic non-invasive fungus-induced rhinosinusitis. This invention also provides methods and materials for diagnosing chronic non-invasive fungus- induced rhinosinusitis and culturing non-invasive fungus from a mammalian mucus sample as well as specific antifungal formulations and medical devices for treating and preventing non- invasive fungus-induced rhinosinusitis.
  • the invention provides methods and materials for treating and preventing other non-invasive fungus-induced mucositis conditions such as chronic otitis media, chronic colitis, and Crohn's disease. Further, the invention involves methods and materials for treating and preventing chronic asthma symptoms.
  • the present invention involving the treatment and prevention of non-invasive fungus-induced inflammation of mucosal tissue by using an antifungal agent is based on the following proposed mechanism of disease progression derived from the discoveries reported herein.
  • most, if not all, individuals have fungal organisms living in their mucus. Normally, most individuals tolerate these non-invasive organisms and live normal disease-free lives. For unknown reasons, some individuals do not tolerate these fungal organisms and begin to mount an immune response against them. As the immune response progresses, eosinophils accumulate within the local tissue.
  • Eosinophil granules contain many toxic molecules such as eosinophil cationic protein (ECP), eosinophil peroxidase (EPO), and major basic protein (MBP).
  • ECP eosinophil cationic protein
  • EPO eosinophil peroxidase
  • MBP major basic protein
  • these toxic molecules can damage both the targeted foreign microorganisms (e.g., fungus) as well as self tissues.
  • the degree of damage caused by eosinophil accumulation and eosinophil degranulation varies significantly from slight inflammatory pain and discomfort to major structural abnormalities such as tissue and bone destruction and the formation of polyps, polypoid structures, and other tumors.
  • self tissues Once self tissues are damaged, the individual can have an increased susceptibility to bacterial infections as well.
  • the characteristic inflammatory responses, resulting damages, and resulting bacterial infections observed within most, if not all, chronic rhinosinusitis patients are actually triggered by non-invasive fungal organisms.
  • the discovery that chronic asthma symptoms can be treated and prevented with antifungal agents when directly mucoadministered to the airways by way of nasal-paranasal irrigation suggests that antifungal agents can be effective when directly mucoadministered to the airways by inhalation through the nose or mouth.
  • the methods and materials described herein have the potential to treat millions of people suffering from chronic rhinosinusitis, chronic otitis media, chronic colitis, Crohn's disease, and any other non-invasive fungus- induced mucositis condition as well as chronic asthma.
  • a non-invasive fungus-induced mucositis is an inflammation, not an infection.
  • inflammations are fundamentally and clinically different from infections.
  • An infection is defined as the growth of an organism within tissue.
  • an infection is characterized as an invasive disease meaning that an infectious organism enters the tissue of a host and then triggers a host immune response and/or causes damage.
  • the role of the infectious organism is typically that of an invasive pathogen.
  • an infected individual can be immunocompetent or immunocompromised. When the infected individual is immunocompromised, the infection is often termed an "opportunistic" infection.
  • infections can be acute or chronic depending upon multiple factors such as the competence of the infected individual's immune system, the nature of the invasive pathogen, and the availability of medical treatments.
  • an inflammation is characterized as a localized protective response that serves to destroy, dilute, and/or sequester an injurious agent or insult.
  • inflammatory responses typically result in redness, swelling, heat, and pain.
  • the localized protective response is against a non-invasive fungal organism living outside the tissue (e.g., within mucus).
  • some individuals suffering from a non-invasive fungus- induced mucositis are atopic and/or immunocompetent.
  • the role of the injurious agent i.e., fungus
  • the injurious agent is that of a non-invasive allergen.
  • a non- invasive fungus-induced mucositis is an allergic reaction mounted by the individual's immune system against a fungal organism living outside an individual's tissue.
  • the invention provides methods and materials that reduce the presence of fungal organisms within mucus to a level and for a period of time such that the characteristic inflammatory responses and resulting damages associated with mucositis are stopped, treated, or prevented.
  • reducing the presence of fungal organisms within mucus to treat or prevent mucositis is similar to removing an allergen (e.g., pollen) from the presence of an individual suffering from an allergic reaction (e.g., hay fever).
  • an allergen e.g., pollen
  • the allergic reaction against, for example, pollen is not an infection but an inflammation.
  • a non-invasive fungus-induced mucositis is defined as an inflammation of any mucosal tissue induced by a non-invasive fungal organism.
  • mucosal tissue include, without limitation, the mucosa of the mouth, gut, nasal passages, paranasal sinuses, airways of the lung, trachea, middle ear, eustachian tube, vagina, and urethra.
  • an inflammation of a mucosal tissue can be determined using any of the methods commonly known to a skilled artisan.
  • an individual can be identified as having an inflammation of a mucosal tissue upon examination of a tissue biopsy as well as by visual examination, endoscopic analysis, and image analysis techniques (e.g., X-rays, CT scans, and magnetic resonance imagery (MRI) scans) since the various inflamed mucosal anatomies tend to exhibit observable abnormal characteristics.
  • image analysis techniques e.g., X-rays, CT scans, and magnetic resonance imagery (MRI) scans
  • diagnostic methods can be used to determine if a particular mucositis is a non-invasive fungus-induced mucositis.
  • diagnostic methods include, without limitation, reviewing the affected individual's prior medical conditions and treatments, interviewing and evaluating the affected individual, and collecting and analyzing biological samples from the affected individual.
  • Interviewing and evaluating an affected individual can also help identify a non-invasive fungus-induced mucositis.
  • individuals suffering from chronic mucositis symptoms such as airway obstructions, loss of smell, loss of hearing, wheezing, dyspnea, coughing, head ache, and facial pressure may have a non-invasive fungus-induced mucositis.
  • a non-invasive fungus-induced mucositis can be ruled out in individuals that exhibit the symptoms of an infection such as fever, fungal dissemination, fungemia, increase in polymorphonuclear leukocytes, and acute onset.
  • recurrent bacterial infections can indicate an underlying non-invasive fungus- induced mucositis condition since chronic inflammation can lead to the destruction of the epithelium and thus increase the individual's susceptibility to bacterial infection.
  • multiple diagnostic tests can be performed to help identify a non-invasive fungus-induced mucositis. For example, a common allergy screen using a panel of fungal and non-fungal antigens can be used to determine if an individual is atopic since some cases of non-invasive fungus-induced mucositis involve atopic individuals.
  • immuno-based tests for the presence of anti-fungal antigen antibodies tests for abnormal pulmonary function with or without methacholine, audiograms, and tympanograms can be used to identify a non-invasive fungus-induced mucositis.
  • Collecting and analyzing biological samples from an affected individual can help identify a non-invasive fungus-induced mucositis.
  • biological samples such as mucus, stool, urine, sputum, and blood can be collected and analyzed for signs that indicate the involvement of a non-invasive fungal organism.
  • Such signs can include, without limitation, the presence of any antigenic marker for non-invasive fungus-induced mucositis; the presence of eosinophils, eosinophil products (e.g., MBP and ECP), antibodies, fungal antigens, or fungal organisms within a mucus, stool, urine, or sputum sample; and the absence of fungal organisms within a blood sample.
  • eosinophils e.g., MBP and ECP
  • the identification of allergic mucus i.e., mucus that contains evidence of eosinophil presence
  • Such evidence of eosinophil presence includes, without limitation, the presence of intact eosinophils, necrotic eosinophils, and eosinophil products.
  • Many methods for detecting the presence of these various signs and markers within a biological sample are well known in the art and can be used.
  • the presence of eosinophils within allergic mucus can be determined using a hematoxylin/eosin stain followed by microscopic examination.
  • a tissue biopsy can be collected and analyzed for the lack of invasive fungus.
  • immuno-based assays can be used to detect the presence of various signs of a non-invasive fungus-induced mucositis within a biological sample.
  • Many immuno-based assays are well known in the art including, without limitation, enzyme-linked immunosorbent assays (ELISA) and radioallergosorbant tests (RAST).
  • ELISA enzyme-linked immunosorbent assays
  • RAST radioallergosorbant tests
  • the methods of using RAST are described, for example, in McRury J et al. (Clin Exp Immunol 65:631-638 (1986)), Mabry RL and Manning S ⁇ Otolaryngol Head Neck Surg 113:721-723 (1995), and Lynch NR et al.(Int Arch Allergy Immunol 114:59-67 (1997)).
  • Immuno-based assays can use polyclonal antibodies, monoclonal antibodies, or fragments thereof that have specificity for an antigen that can be used as a diagnostic marker for non-invasive fungus-induced mucositis.
  • monoclonal antibodies having specificity for fungal organisms known to cause non-invasive fungus-induced mucositis can be produced and used to screen biological samples.
  • Such antibodies can be produced using methods described elsewhere (Zeidan et al., Experimental Approaches in Biochemistry and Molecular Biology, William C. Brown Publisher (1996) and Seaver, Commercial Production of Monoclonal Antibodies: A Guide for Scale-Up, Marcel Dekker Inc., New York, NY (1987)).
  • a mouse can be immunized with a sample of a fungal organism isolate. Several weeks later lymphocytes from spleen of the immunized mouse can be recovered and fused with myeloma cells to produce hybridoma cells. Hybridoma cells exhibiting specificity for the immunizing fungal isolate then can be isolated and monoclonal antibody preparations produced.
  • the external bony framework of the nose consists of two oblong nasal bones.
  • One nasal bone is disposed on each side of a midline, with the two bones forming an arched cross section.
  • the nasal septum divides the nasal cavity in half.
  • the lateral nasal wall has three turbinates that increase the mucosal surface area of the nasal cavity or vestibule.
  • the nasal vestibule is bounded by the nasal septum and lateral wall. This large surface area of the turbinates and nasal septum promotes extensive contact with inspired air, thus facilitating humidification, particle removal, and temperature regulation of inspired air.
  • the paranasal sinuses are air-containing spaces joining the nasal cavity by means of openings or ostia.
  • the paranasal sinuses are commonly asymmetrical in shape and location, and include the maxillary, frontal, ethmoid, and sphenoid sinuses. Suggested functions of the paranasal sinuses include lightening the bones of the skull, providing mucus for the nasal cavity, and acting as resonant chambers for the production of sound.
  • the maxillary sinuses are the largest of the paranasal sinuses. Each maxillary sinus is located in the maxilla and opens into the middle meatus.
  • the frontal sinuses are located in the frontal bone and are superior and medial to the orbit of the eye. The frontal sinuses also empty into the middle meatus.
  • the ethmoid sinuses are numerous and irregularly shaped air spaces opening into the middle and superior meatuses.
  • the sphenoid sinus is in the sphenoid bone and is posterior to both the eye and the upper portion of the nasal cavity.
  • the sphenoid sinus drains into the superior meatus.
  • Mucosal tissue lines both the nasal cavity and the paranasal sinuses, and generally comprises an epithelial layer, connective tissue, and mucus glands.
  • a layer of mucus normally covers the mucosa.
  • Mucus that is secreted from mucosa serves to trap particles and to prevent dehydration of the nasal and paranasal tissues that are otherwise exposed to air.
  • the mucus is normally transported by cilia toward the nasopharynx and then swallowed.
  • Symptoms of rhinosinusitis include, without limitation, nasal airway obstruction, loss of smell, facial pain, head ache, post nasal drip, and rhinorrhea.
  • nasal airway obstruction Upon examination, the presence of thick mucus or the visual identification of nasal or paranasal obstruction with mucus or polyps often indicates a rhinosinusitis condition.
  • Nasal polyps are outgrowths from the nasal-paranasal mucosa that are typically smooth, gelatinous, semitranslucent, round or pear shaped, and pale. In general, nasal polyps are located on the lateral wall of the nose, usually in the middle meatus or along the middle and superior turbinates.
  • nasal polyps arise from the ethmoid sinus but some polyps originate in the maxillary sphenoid sinuses.
  • the mass of a nasal polyp is composed mainly of edematous fluid with sparse fibrous cells and a few mucous glands.
  • the surface epithelium of nasal and paranasal polyps generally reveals squamous metaplasia.
  • Eosinophils are usually present in polyps in moderate to large numbers, and it is now known that nasal polyp fluid contains greater than normal concentrations of IgA, IgE, IgG, and IgM antibodies as well as abnormally high concentrations of IL-5, a cytokine that contributes to eosinophil activation and survival.
  • the presence of nasal polyps is not a risk factor for rhinosinusitis, but rather an end stage of chronic inflammation.
  • AFS non-invasive fungus-induced rhinosinusitis condition
  • any method known in the art that is used to identify AFS can be used to identify non-invasive fungus-induced rhinosinusitis (Cody DT et al. Laryngoscope 104:1074-1079 (1994) and Kupferberg SB et al, Otolaryngol. Head Neck Surg 117:35-41 (1997)).
  • non-invasive fungus-induced rhinosinusitis can be identified by the presence of inspissated mucus that contains clumps or sheets of necrotic eosinophils, Charcot-Leyden crystals, and non-invasive fungal hyphae.
  • image analysis such as MRI and CT scans can be used to identify non- invasive fungus-induced rhinosinusitis since such conditions typically exhibit a characteristic appearance and often cause bone erosion in adjacent structures (Quraishi et al, Otolaryngol. Head Neck Surg.
  • results using currently available diagnostic methodology indicate that about three to eight percent of chronic rhinosinusitis cases requiring surgery are AFS cases.
  • these current AFS diagnostic methods involve criteria such as the presence of a characteristic appearance on a CT scan, the presence of allergic mucus, and the presence of fungal organisms within mucus samples as confirmed by either histology or fungal growth in culture.
  • the present invention demonstrates that greater than about 90 percent of all chronic rhinosinusitis cases have a fungal etiology based on a better understanding of chronic rhinosinusitis, improved diagnostic procedures, and the impressive success rate of the antifungal treatment approaches described herein.
  • the present invention demonstrates that the ability to grow fungal organisms from a mucus sample is not a useful criterion for diagnosing a non-invasive fungus-induced rhinosinusitis condition, such as AFS, since most, if not all, humans have fungal organisms within their nasal-paranasal mucus (See Example 1). It is noted, however, that collecting, analyzing, and/or culturing fungal organisms from a nasal-paranasal mucus sample can provide useful diagnostic information. Such information can include, without limitation, information about the level of fungal organisms and the number of different fungal species present within a particular mucus sample.
  • the present invention teaches that special care should be taken to preserve the mucus for analysis and that the presence of allergic mucus can be used to identify non-invasive fungus-induced rhinosinusitis.
  • recurrent bacterial infections within the nasal-paranasal anatomy can indicate non- invasive fungus-induced rhinosinusitis.
  • Any individual that had a previous episode of rhinosinusitis is at risk for developing non-invasive fungus-induced rhinosinusitis.
  • elderly individuals as well as individuals having cystic fibrosis, asthma, and a family history of nasal problems or allergies can be at risk for developing non-invasive fungus-induced rhinosinusitis.
  • individuals that are exposed to significant levels of allergens e.g., fungus spores, pollen, and chemicals
  • allergens e.g., fungus spores, pollen, and chemicals
  • the ear can be divided into three parts: the external ear, middle ear, and internal ear.
  • the middle ear is a cavity that is connected to the nasopharynx by the eustachian tube.
  • the middle ear is separated from the opening of the external ear by the tympanic membrane and contains a chain of three small bones that connect the tympanic membrane with the internal ear. Mucosal tissue lines most of the middle ear space.
  • otitis media Individuals suffering from an inflammation of the mucosal tissue of the middle ear (otitis media) can be identified based on a medical history of middle ear afflictions, visual examination, tissue biopsy, and symptoms such as a loss of hearing, otorrhea, and middle ear effusion.
  • a non-invasive fungus-induced otitis media condition can be identified by (1) collecting and analyzing fluid or mucus samples from the middle ear for fungal organisms or eosinophil presence, (2) tissue biopsy analysis for non- invasive fungal organisms, (3) an audiogram consistent with conductive hearing loss, and (4) a flat tympanogram.
  • tissue biopsy analysis for non-invasive fungal organisms
  • an audiogram consistent with conductive hearing loss and (4) a flat tympanogram.
  • identifying the presence of fungal organisms in samples collected from the middle ear can indicate a non-invasive fungus-induced inflammatory condition since the middle ear normally is quite sterile. Any individual that had a previous episode of otitis media is at risk for developing non-invasive fungus-induced otitis media.
  • young individuals e.g., infants and toddlers
  • individuals having a family history of ear problems or allergies can be at risk for developing non-invasive fungus- induced otitis media.
  • Individuals suffering from an inflammation of the intestines can be identified using methods and materials commonly known in the art. For example, tissue biopsy analysis as well as endoscopic analysis can be used to identify intestinal mucositis conditions such as intestinal polyposis.
  • symptoms such as diarrhea, abdominal cramps, gas, and nausea can indicate inflammation of the intestines.
  • a non-invasive fungus-induced intestinal mucositis condition can be identified by the presence of fungal organisms, eosinophils, or eosinophil products within stool s.amples.
  • tissue biopsies revealing the presence of non-invasive fungal organisms can indicate a non-invasive fungus-induced intestinal mucositis condition.
  • Any individual that had a previous episode of an intestinal inflammatory condition is at risk for developing non-invasive fungus-induced intestinal mucositis.
  • elderly individuals as well as individuals having a family history of digestive problems, intestinal polyposis, or allergies can be at risk for developing non-invasive fungus-induced intestinal mucositis.
  • Any fungal organism living in the mucus of a mammal can be a non- invasive fungal organism that is capable of inducing mucositis since it is the mere presence of the organism in an intolerant individual's mucus that causes inflammation.
  • all fungal organisms previously identified in mucus samples of AFS patients can be non-invasive fungal organisms capable of inducing non-invasive fungus-induced mucositis including, without limitation, Absidia,
  • Aspergillus flavus Aspergillus flavus, Aspergillus fumigatus, Aspergillus glaucus, Aspergillus nidulans, Aspergillus versicolor, Alternaria, Basidiobolus, Bipolaris, Candida albicans, Candida lypolytica, Candida parapsilosis, Cladosporium, Conidiobolus, Cunninahamella, Curvularia, Dreschlera, Exserohilum, Fusarium, Malbranchia, Paecilomvces, Penicillium, Pseudallescheria, Rhizopus, Schizophylum, .and
  • fungal organisms that were, until now, not identified in mucus samples of patients diagnosed positive for AFS can be non-invasive fungal organisms capable of causing a non-invasive fungus-induced mucositis including, without limitation, Acremonium, Arachniotus citrinus, Aurobasidioum, Beauveria, Chaetomium, Chryosporium, Epicoccum, Exophilia jeanselmei, Geotrichum, Oidiodendron, Phoma, Pithomyces, Rhinocladiella, Rhodoturula, Sagrahamala, Scolebasidium, Scopulariopsis, Ustilago, Trichoderma, .and Zygomycete.
  • a list of additional fungal organisms that can be non-invasive fungal organisms capable of inducing a non-invasive fungus-induced mucositis can be found in most taxonomic mycology text books.
  • mucus can be collected from the surface of any mucosal tissue by using a collection solution to flush the mucus-containing cavity.
  • Proper mucus collection techniques should maximize recovery of a mucus-containing collection solution by allowing sufficient penetration of the appropriate anatomic cavities and by minimizing collection solution absorption by the individual.
  • Vasoconstrictor agents can be used to maximize mucus collection and mucolytic agents can be used to dissolve obstructive mucus such that collection solution penetration is enhanced.
  • vasoconstrictor agent can include, without limitation, phenylephrine hydrochloride (NEO-SYNEPHRINE ® ; Sanofi Pharmaceuticals), cocaine, and epinephrine.
  • a mucolytic agent is any agent that liquefies mucus such that it can be recovered from the patient.
  • Suitable mucolytic agents can include, without limitation, N-acetyl-L-cysteine (MUCOSILTM; Dey Laboratories) and recombinant human DNase (PULMOZYME ® ; Genentech, Inc.). Any administered vasoconstrictor agent or mucolytic agent should be allowed to take effect by waiting a sufficient period of time after administration such as about two to five minutes.
  • MUCOSILTM N-acetyl-L-cysteine
  • PULMOZYME ® recombinant human DNase
  • an individual is prepared to receive a collection solution in at least one nostril or nasal-paranasal cavity by directing the individual to inhale and to lower the chin, or in some other way constrict the access of fluids out of the mouth and down the esophagus. In a vertically sitting or standing individual, these maneuvers tend to minimize the loss or ingestion of the collection solution. Other maneuvers are also possible provided this goal is achieved.
  • an injection and collection system is configured. In general, the configuration is such that a collection solution can be administered to an individual's nostril .and then efficiently collected in a container.
  • the injection system can be, without limitation, a syringe with a curved blunt needle or tube assembly.
  • the container can be any type of container that holds liquid.
  • the container can be, without limitation, a storage container that is suitable for use as a transporter or sealable apparatus such that the collected sample can be handled or shipped.
  • These containers also can contain an agent such as a preservative or antibacterial agent depending upon the desired use of the mucus sample.
  • a collection solution is administered into an individual's nostril and collected. Before administration, the individual can be instructed to expel the collection solution upon sensing the fluid in its nasal-paranasal anatomy. Alternatively, the individual can be instructed to expel the collection solution simultaneously with the administration.
  • the collection solution can be forcibly injected into at least one nostril or side of the nasal- paranasal anatomy.
  • the volume of the collection solution can vary according to the individual and the state of the mucositis.
  • fluid volumes can be, without limitation, between about 0.1 mL to about 100 mL or more, and specifically between about 0.1 mL and about 25 mL.
  • the collection solution can be, without limitation, a saline solution, water, and any other suitable solution appropriate for contacting mucosal tissue.
  • the collection solution can contain other agents that may be useful for the collection of mucus such as a mucolytic agent.
  • a collection solution One goal of a collection solution is to dislodge and remove mucus within mucus-containing cavities.
  • the penetrating effect of a mucolytic agent within a collection solution can help liquefy thick obstructive mucus.
  • the combination of the force of administration with the near simultaneous pressurized expulsion by an individual can help dislodge and collect mucus.
  • a collection solution can be administered during a period of less than about 5 seconds per side.
  • a collection solution can be administered during a period of less than about 3 seconds.
  • the time period of collection solution administration can be extend beyond 5 seconds depending on specific factors such as the degree of inflammation, the presence of obstructions, and the size of the individual.
  • a greater than 5 second administration can be used when very small volumes or streams of collection solution are desired.
  • Other collection procedures also can be used to collect mucus samples, particularly if an individual is unable to comply or cope with a liquid collection procedure.
  • additional procedures are well known in the art and include, without limitation, the surgical removal of mucus, a swab or mechanical mucus extraction procedure, and pressure or vacuum systems that extract mucus.
  • these other collection procedures as well as the methods and materials described herein can be modified or adapted to obtain biological fluids from other areas of the body such as the middle ear and intestines.
  • the sample can be analyzed for the presence of markers that indicate the involvement of non-invasive fungus-induced mucositis.
  • a mucus sample can be examined to determine the presence of allergic mucus.
  • fungal organisms can be cultured and analyzed from a mucus sample using the techniques described herein as well as those techniques known in the art.
  • FIGS 3 and 4 depict an exemplary device 10 for aspirating and collecting mucus and other liquids.
  • Device 10 includes upper member 12, collection retainer 14, and collection tube 16.
  • Central portion 22 may generally define opening 29 therein.
  • Valve 30 is operably disposed within opening 29.
  • Threaded portion 24 may extend downwardly from central portion 22.
  • Connecting portion 26 extends radially from central portion 22, is generally circular in cross-section in this embodiment, and defines bore 32. Bore 32 communicates the exterior of device 10 with an interior portion thereof.
  • Tube receiving member 28 extends generally radially from central portion 22.
  • Tube receiving member 28 is disposed generally opposite connection portion 26 in this embodiment.
  • Tube receiving member 28 defines bore 34.
  • bore 34 communicates the exterior of device 10 to the interior thereof.
  • retainer 14 is threadably received onto threaded portion 24.
  • Retainer 14 may be secured to central portion 22 by other known means.
  • Collection tube 16 extends from and is disposed within bore 34.
  • a length of tube 16 may be disposed within the interior of retainer 14 to facilitate placement of collected material.
  • Collection tube 16 defines lumen 36 through which the collected mucus travels.
  • tube 16 comprises a flexible memory means to facilitate adaptation to different patient anatomies.
  • tube 16 remains conformed to a desired and flexible configuration, for example, as depicted by the phantom lines in the Figure 3.
  • Further means to facilitate travel of the mucus through the collection tube and device 10 may include a tube or device liner having material characteristics designed to minimize adherence of the mucus thereto.
  • device 10 is designed for a single use.
  • Device 10 may be made from a number of materials, however, synthetic resins such as polyethylene may be used.
  • Connecting portion 26 connects device 10 to a vacuum hose 38.
  • connecting portion 26 may have an outer configuration such that an air tight fit to vacuum hose 38 results.
  • Valve 30 adjusts the amount of vacuum communicated through lumen 36. By adjusting valve 30, a gradually increasing or decreasing amount of vacuum may be applied thereto.
  • valve 30 includes a generally elongate slit which is configured with a sliding member. The sliding member may be adjusted by the user so that all, none, or a portion of the elongate slit is exposed, thereby adjusting the vacuum communicated to lumen 36.
  • Another example includes an "IV" type of valve which utilizes a roller valve to adjustably constrict a draw or collection tube.
  • tube receiving member 28 and collection tube 16 extend generally perpendicularly from a longitudinal axis of retainer 14. This enables the users to better position collection tube 16 when recovering mucus and other liquids.
  • other collection containers are possible within the scope of this invention which conform comfortably to a patient's facial anatomy, and which may be readily held in place by either the patient or a health care provider. Such embodiments may rely on vacuum, gravity, or other collection mechanisms provided they afford ready access for fluids being injected into the patient while simultaneously allowing drainage or withdrawal of the fluids and mucus from the patient.
  • lumen 36 is between about 1 mm and 10 mm in diameter, and between about 5 cm and 50 cm in total length.
  • Exemplary retainer 14 is generally between about 1" to 3" in diameter and 3" to 6" in height, although various other sizes may be useful.
  • Device 10 is advantageously utilized to obtain mucus or fluid samples from a patient's nasal, paranasal, or pulmonary anatomy.
  • device 10 is connected to a vacuum source and valve 30 is adjusted as desired.
  • Tube 16 is configured to a desired position. Tube 16 is then inserted into a portion of the patient's anatomy from which mucus or fluid is to be obtained.
  • Valve 30 is further adjusted as necessary to obtain the sample, yet assure safety to the patient.
  • the obtained mucus or fluid is collected in retainer 14. Once collection is complete, retainer 14 may be detached from upper member 12 for storage or shipment of the obtained mucus or fluid sample. Culturing Fungal Organisms from a Mucus Sample
  • a mucus sample can be prepared for fungal organism culturing by treating the sample with a mucolytic agent such as N-acetyl-L-cysteine or dithiothreitol (DTT) to enhance or facilitate further liquefaction of mucus.
  • a mucolytic agent such as N-acetyl-L-cysteine or dithiothreitol (DTT)
  • the mucus sample can be mixed and incubated at room temperature. This liquefaction allows fungal organisms present within mucus to be released.
  • mucus Once liquefied, mucus can be isolated by centrifugation or other means since mucus typically forms a layer separate from the other solutions (i.e., collection solution). Once isolated, the mucus can be mixed and an aliquot placed in contact with an appropriate fungal growth medium such as growth medium agar plates.
  • a fungal growth medium is any medium that can support the growth of a fungal organism including, without limitation, RPMI-1649, Delbecco's modified eagles medium (DMEM), inhibitory mold agar (IMA), and Bay agar.
  • the fungal growth medium can contain antibacterial agents (e.g., chloramphenicol and ciprofloxacin) to prevent the growth of bacteria.
  • the cultures can be incubated at an optimal temperature, for example, between about 20°C and 37°C and, in some instances, between about 25°C and 35°C.
  • An optimum temperature can be assessed by placing duplicate cultures at various temperatures and comparing growth rates. Typically, cultures are incubated between about two to thirty-five days at about 30°C.
  • Antifungal agents can be mucoadministered to a mammal in an amount, at a frequency, and for a duration effective to treat or prevent non-invasive fungus- induced mucositis.
  • An "antifungal agent” is any agent that is active against a fungal organism.
  • an antifungal agent is any agent that prevents the growth of or kills a fungal organism such as antifungal polyene macrolides, tetraene macrolides, pentaenic macrolides, fluorinated pyrimidines, imidazoles, triazoles, azoles, halogenated phenolic ethers, thiocarbamates, and allylamines.
  • antifungal agents can be agents that interpolate fungal cell wall components or act as sterol inhibitors.
  • Specific antifungal agents within the scope of the invention include, without limitation, amphotericin B, flucytosine, ketoconazole, miconazole, itraconazole, fluconazole, griseofulvin, clotrimazole, econazole, terconazole, butoconazole, oxiconazole, sulconazole, saperconazole, voriconazole, ciclopirox olamine, haloprogin, tolnaftate, naftifme, nystatin, natamycin, terbinafine hydrochloride, morpholines, butenafine undecylenic acid, Whitefield's ointment, propionic acid, and caprylic acid as well as those agents that can be identified as antifungal agents using methods well known in the art.
  • an important aspect of this invention involves treating that patient with an effective antifungal agent (e.g., an antifungal agent that prevents the growth of, or kills, the fungal organism acting as the etiological agent).
  • an effective antifungal agent e.g., an antifungal agent that prevents the growth of, or kills, the fungal organism acting as the etiological agent.
  • Such fungal organisms acting as etiological agents can be identified using the collection and culture methods described herein.
  • mucoadministration refers to any type of administration that places an administered agent in contact with mucus.
  • any intravenously administered agent that does not exit the blood stream is not considered a mucoadministered agent because the agent failed to contact mucus.
  • mucoadministration can be subdivided into “direct” and “indirect” mucoadministration.
  • direct mucoadministration refers to any type of administration that places an administered agent in direct contact with a targeted mucus prior to crossing epithelium.
  • injections of an agent into a cavity containing mucus is considered direct mucoadministration if the agent contacts mucus even though an injection means (e.g., needle, tube, or catheter) may be used to cross an epithelium.
  • an injection means e.g., needle, tube, or catheter
  • using a needle to bypass the tympanic membrane and inject an agent into the middle ear is considered a direct mucoadministration that targets middle ear mucus.
  • any intravenously a-dministered agent that subsequently exits the blood stream, permeates epithelium, and contacts mucus is not considered a directly mucoadministered agent because the agent crossed epithelium prior to contacting mucus.
  • the intravenously administered agent is considered an indirectly mucoadministered agent since the term "indirect mucoadministration" means any type of administration that places an administered agent in contact with a targeted mucus after crossing epithelium.
  • direct mucoadministration means any type of administration that places an administered agent in contact with a targeted mucus after crossing epithelium.
  • an injection means such as a needle, tube, or catheter to deliver an agent past epithelium and into direct contact with mucus does not necessarily mean the administration is an indirect mucoadministration.
  • an oral administration can be either a direct or indirect mucoadministration depending on the targeted mucus.
  • an agent can be swallowed and then traverse the esophagus, stomach, and small intestine to come in direct contact with mucus in the large intestine, without having crossed an epithelium (i.e., direct mucoadministration).
  • the orally administered agent could be absorbed by the gut, accumulate systemically, and permeate the nasal epithelium to come in contact with nasal mucus (i.e., indirect mucoadministration).
  • the direct and indirect nature of mucoa-dministration depends upon the specific route of administration as well as the specific location of the targeted mucus. Typical routes of direct and indirect mucoadministration for various mucus locations of a mammal are described below.
  • an effective amount of an antifungal agent or formulation containing an antifungal agent can be any amount that reduces, prevents, or eliminates non- invasive fungus-induced mucositis upon mucoadministration in a mammal without producing significant toxicity to the mammal.
  • an effective amount can be any amount greater than or equal to the minimum inhibitory concentration (MIC) for a fungal organism or isolate present within a particular individual's mucus that does not induce significant toxicity to the individual upon mucoadministration.
  • MIC minimum inhibitory concentration
  • Some antifungal agents may have a relatively large concentration range that is effective while others may have a relatively narrow effective concentration range.
  • the effective amount can vary depending upon the specific fungal organism or isolate since certain organisms and isolates are more or less susceptible to particular antifungal agents.
  • Such effective amounts can be determined for individual antifungal agents using commonly available or easily ascertainable information involving antifungal effectiveness concentrations, animal toxicity concentrations, and tissue permeability rates.
  • non-toxic antifungal agents typically can be directly or indirectly mucoadministered in any amount that exhibits antifungal activity within mucus.
  • antifungal agents that do not permeate mucosal epithelium typically can be directly mucoadministered in any amount that exhibits antifungal activity within mucus.
  • effective amounts also can be determined by routine experimentation in vitro or in vivo.
  • a patient having a non-invasive fungus-induced mucositis condition can receive direct mucoadministration of an antifungal agent in an amount close to the MIC calculated from in vitro analysis. If the patient fails to respond, then the amount can be increased by, for example, ten fold. After receiving this higher concentration, the patient can be monitored for both responsiveness to the treatment and toxicity symptoms, .and adjustments made accordingly.
  • an effective .amount can be about 0.01 ng to about 1000 mg per kg of body weight of the mammal per administration when directly mucoadministered.
  • an effective amount can be a volume of about 0.01 mL to about 1 liter per nostril per administration of a solution containing about 0.01 mg of amphotericin B per liter to about 1000 mg of amphotericin B per liter.
  • an effective .amount can be 20 mL per nostril per administration (e.g., two to four tir ⁇ es daily) of an irrigation solution containing about 100 mg of amphotericin B per liter of saline or water.
  • the saline or water is sterile.
  • the effective amount can remain constant or can be adjusted as a sliding scale or variable dose depending on the individual's response to treatment. Effective amounts for other antifungal agents can be determined by a person of ordinary skill in the art using routine experimentation in view of the multiple teachings described herein.
  • an effective amount of any antifungal agent directly mucoadministered can be about 0.01 ng to about 1000 mg per kg of body weight of the mammal per administration.
  • the MIC values for voriconazole range from about 0.003 ⁇ g/mL to about 4 ⁇ g/mL depending upon the specific fungal organism or isolate tested.
  • the MIC values range from about 0.25 ⁇ g/mL to greater than about 64 ⁇ g/mL.
  • an effective amount equivalent based on the effective amount of a common antifungal agent.
  • the direct mucoadministration of about 20 mL per nostril per administration (e.g., twice daily) of an amphotericin B irrigation solution containing about 100 mg of amphotericin B per liter is an effective amount as demonstrated herein.
  • the effects produced by this effective amount can be used as a reference point to compare the effects observed for other antifungal agents used at varying concentrations. Once an equivalent effect is observed, then the specific effective amount for that particular antifungal agent can be determined. In this case, that particular amount would be termed an amphotericin B effective amount equivalent.
  • the frequency of mucoadministration, duration of treatment, combination of other antifungal agents, site of administration, degree of inflammation, and the anatomical configuration of the treated area may require an increase or decrease in the actual effective amount mucoadministered.
  • the frequency of mucoadministration can be any frequency that reduces, prevents, or eliminates non-invasive fungus-induced mucositis in a mammal without producing significant toxicity to the mammal.
  • the frequency of mucoadministration can be from about four times a day to about once a month, or more specifically, from about twice a day to about once a week.
  • the frequency of mucoadministration can remain constant or can be variable during the duration of treatment.
  • various factors can influence the actual frequency of mucoadministration used for a particular application. For example, the effective amount, duration of treatment, combination of other antifungal agents, site of administration, degree of inflammation, and the anatomical configuration of the treated area may require an increase or decrease in mucoadministration frequency.
  • An effective duration for antifungal agent mucoadministration can be any duration that reduces, prevents, or eliminates non-invasive fungus-induced mucositis in a mammal without producing significant toxicity to the mammal.
  • the effective duration can vary from several days to several weeks, months, or years.
  • the effective duration for the treatment of non-invasive fungus-induced mucositis can range in duration from several days to several months.
  • an effective duration can range from about 10 days to about 30 days.
  • an effective duration can range from about 30 days to greater than about 80 days.
  • an effective duration can be from about 10 days to greater than about 30 days, or even greater than about 90 days.
  • prophylactic treatments are typically longer in duration and can last throughout an individual's lifetime. Multiple factors can influence the actual effective duration used for a particular treatment or prevention regimen.
  • an effective duration can vary with the frequency of antifungal agent administration, effective antifungal agent amount, combination of multiple antifungal agents, site of administration, degree of inflammation, and anatomical configuration of the treated area.
  • the specific antifungal agent used can influence the actual effective duration.
  • an effective duration for treating non-invasive fungus-induced rhinosinusitis can be about 30 days for amphotericin B and about 7 days for itraconazole. It is noted that diagnostic algorithm methods can be devised to determine or reflect appropriate effective doses, durations, and frequencies.
  • a formulation containing an antifungal agent can be in any form provided the formulation can be mucoadministered to a mammal in an amount, at a frequency, and for a duration effective to prevent, reduce, or eliminate a non- invasive fungus-induced mucositis.
  • a formulation within the scope of the invention can be in the form of a solid, liquid, and/or aerosol including, without limitation, powders, crystalline substances, gels, pastes, ointments, salves, creams, solutions, suspensions, partial liquids, sprays, nebulae, mists, atomized vapors, tinctures, pills, capsules, tablets, and gelcaps.
  • the formulation can contain a cocktail of antifungal agents.
  • a formulation within the scope of the invention can contain, without limitation, one, two, three, four, five, or more different antifungal agents.
  • formulations within the scope of the invention can contain additional ingredients including, without limitation, pharmaceutically acceptable aqueous vehicles, pharmaceutically acceptable solid vehicles, steroids, mucolytic agents, antibacterial agents, anti-inflammatory agents, immunosuppressants, dilators, vaso-constrictors, decongestants, leukotriene inhibitors, anti-cholinergics, anti-histamines, therapeutic compounds, and combinations thereof.
  • a formulation can contain any one or more compounds known to be effective for inhibiting the gag reflex of a mammal.
  • a pharmaceutically acceptable aqueous vehicle can be, for example, any liquid solution that is capable of dissolving an antifungal agent and is not toxic to the particular individual receiving the formulation.
  • pharmaceutically acceptable aqueous vehicles include, without limitation, saline, water, and acetic acid.
  • pharmaceutically acceptable aqueous vehicles are sterile.
  • a pharmaceutically acceptable solid vehicle can be formulated such that the antifungal agent is suitable for oral administration.
  • capsules or tablets can contain an antifungal agent in enteric form. The dose supplied by each capsule or tablet can vary since an effective amount can be reached by administrating either one or multiple capsules or tablets. Any well known pharmaceutically acceptable material such as gelatin and cellulose derivatives can be used as a pharmaceutically acceptable solid vehicle.
  • a pharmaceutically acceptable solid vehicle can be a solid carrier including, without limitation, starch, sugar, or bentonite.
  • a tablet or pill formulation of an antifungal agent can follow conventional procedures that employ solid carriers, lubricants, and the like.
  • Steroids can be any compound containing a hydrocyclopentanophenanthrene ring structure.
  • Examples of steroids include, without limitation, prednisone, dexamethasone, and hydrocortisone.
  • Mucolytic agents can be any compound that liquefies mucus. Suitable mucolytic agents can include, without limitation, N-acetyl-L-cysteine (MUCOSILTM; Dey Laboratories) and recombinant human DNase (PULMOZYME ® ; Genentech, Inc.).
  • An antibacterial agent can be any compound that is active against bacteria, such as penicillin, erythromycin, neomycin, gentamicin, and clindamycin.
  • An antiinflammatory agent can be any compound that counteracts inflammation, such as ibuprofen and salicylic acid.
  • An immunosuppressant can be any compound that suppresses or interferes with normal immune function, such as cyclosporine.
  • a dilator can be any compound that causes the expansion of an orifice, such as albuterol.
  • a vaso-constrictor can be any compound that constricts or narrows blood vessels, such as phenylephrine hydrochloride (NEO-SYNEPHRINE ® ; Sanof ⁇ Pharmaceuticals), cocaine, and epinephrine.
  • a decongestant can be any compound that acts to reduce nasal-paranasal congestion or swelling, such as pseudoephedrine hydrochloride, phenylpropanolamine, and oxymetazoline.
  • a leukotriene inhibitor can be any compound that inhibits the function or synthesis of a leukotriene, such as Azelastine ® .
  • An anti-cholinergic can be .any compound that blocks parasympathetic nerve impulses, such as ipratropium bromide.
  • An anti-histamine can be any compound that opposes the action of histamine or its release from cells (e.g., mast cells), such as terfenadine and astemizole.
  • a therapeutic compound can be any compound that has a therapeutic effect upon administration.
  • a therapeutic compound can be any compound that blocks or interferes with the interaction of an eosinophil with an immunoglobulin bound to a fungal antigen by targeting, for example, Fc receptor or S-type lectin factor receptor (e.g., galectin-3) interactions.
  • Such compounds can include, without limitation, antibodies such as IgE, IgA, IgG, IgM, and IgD as well as antibody fragments such as Fab, F(ab') 2 , Fc ⁇ RI, Fc ⁇ RII, Fc ⁇ R, Fc ⁇ RII, and Fc ⁇ RI.
  • the mucoadministration of an agent to the nasal-paranasal anatomies can be any type of administration that places the agent in contact with nasal-paranasal mucus.
  • Direct mucoadministration to the nasal-paranasal anatomies can include, without limitation, nasal irrigations, nasal sprays, nasal inhalations, and nasal packs with, for example, saturated gauze provided the administered agent contacts nasal- paranasal mucus prior to crossing epithelium.
  • injections into the nasal- paranasal cavities using, for example, a needle or catheter tube is considered a direct mucoadministration provided the administered agent contacts nasal-paranasal mucus after leaving the needle or catheter tube and prior to crossing epithelium.
  • Any device can be used to directly mucoadminister an agent to the nasal-paranasal anatomy including, without limitation, a syringe, bulb, inhaler, canister, spray can, nebulizer, .and mask.
  • a 20 mL bulb can be used to irrigate the nasal- paranasal anatomy with a liquid form of a formulation containing an antifungal agent.
  • a liquid form of a formulation can be stored at -20°C, 0°C, or room temperature. If stored below room temperature, the formulation typically is warmed prior to application to the nasal/paranasal cavities.
  • Indirect mucoadministration to the nasal-paranasal anatomies can include, without limitation, oral, intravenous, intradermal, and intraperitoneal administrations provided the administered agent contacts nasal-paranasal mucus.
  • any device can be used to indirectly mucoadminister an agent to the nasal-paranasal anatomy including, without limitation, a syringe and regulated release capsule.
  • orally mucoadministered antifungal agents may require higher concentrations to deliver an effective amount to nasal- paranasal mucus than direct mucoadministration by nasal irrigations.
  • An airway is any part of the mammalian anatomy that air traverses during respiration including the mouth, nasal passages, trachea, bronchi, and bronchial tubes.
  • a lung airway is any air passage of the lung lined by mucosa including the bronchi and bronchial tubes.
  • the mucoadministration of an agent to the lung airways can be any type of administration that places the agent in contact with lung airway mucus.
  • Direct mucoadministration to the lung airways can include, without limitation, inhalations, nasal sprays, and nasal irrigations provided the administered agent contacts lung airway mucus prior to crossing epithelium.
  • injections into lung airways using, for example, a needle or catheter tube is considered a direct mucoadministration provided the administered agent contacts lung airway mucus after leaving the needle or catheter tube and prior to crossing epithelium.
  • Any device can be used to directly mucoadminister an agent to the lung airway including, without limitation, a syringe, bulb, inhaler, nebulizer, aerosol canister, spray can, and mask.
  • Indirect mucoadministration to the lung airways can include, without limitation, oral, intravenous, intradermal, and intraperitoneal administrations provided the administered agent contacts lung airway mucus after crossing epithelium.
  • any device can be used to indirectly mucoadminister an agent to lung airways including, without limitation, a syringe and regulated release capsule.
  • enteric mucoadministration of an antifungal agent may require a higher concentration to deliver an effective amount to lung airway mucus than direct mucoadministration by inhalation through the mouth or nose.
  • direct and indirect mucoadministration to the airways including the trachea, nasal passages, and mouth can be accomplished using the methods and material described herein for the lung airways.
  • the mucoadministration of an agent to the middle ear can be any type of administration that places the agent in contact with middle ear mucus.
  • the direct mucoadministration to the middle ear can include, without limitation, ear drops and ear flushes provided the administered agent contacts middle ear mucus prior to crossing epithelium.
  • an ear flush would be considered a direct mucoadministration provided the administered agent contacts middle ear mucus.
  • injections into the middle ear using, for example, a needle or myringotomy tube is considered a direct mucoadministration provided the admimstered agent contacts middle ear mucus after leaving the needle or tube and prior to crossing epithelium.
  • Any device can be used to directly mucoadminister an agent to the middle ear including, without limitation, a syringe and bulb.
  • Indirect mucoadministration to the middle ear can include, without limitation, oral, intravenous, intradermal, and intraperitoneal administrations provided the administered agent contacts middle ear mucus after crossing epithelium.
  • any device can be used to indirectly mucoadminister an agent to the middle ear including, without limitation, a syringe and regulated release capsule.
  • orally mucoadministered antifungal agents may require higher concentrations to deliver an effective amount to middle ear mucus than direct mucoadministration by middle ear injection.
  • the mucoadministration of an agent to the intestines can be any type of administration that places the agent in contact with intestinal mucus.
  • the direct mucoadministration to the intestines can include, without limitation, oral and enema administrations provided the administered agent contacts intestinal mucus prior to crossing epithelium.
  • injections into the digestive tract using, for example, a needle or catheter tube is considered a direct mucoadministration provided the admimstered agent contacts intestinal mucus after leaving the needle or catheter tube .and prior to crossing epithelium.
  • Any device can be used to directly mucoadminister an agent to the intestines including, without limitation, a syringe and regulated release capsule.
  • an antifungal agent can be formulated into a regulated release capsule such that the antifungal agent is released after passing, for example, the stomach (e.g., pH regulated release capsules and time regulated release capsules).
  • Indirect mucoadministration to the intestines can include, without limitation, intravenous, intradermal, and intraperitoneal administrations provided the administered agent contacts intestinal mucus.
  • any device can be used to indirectly mucoadminister an agent to the intestines including, without limitation, a syringe.
  • intravenously mucoadministered antifungal agents may require higher concentrations to deliver an effective amount to intestinal mucus than direct mucoadministration by an enema.
  • Additional Treatments can be used in combination with a formulation containing an antifungal agent to help enhance the treatment or prevention of non- invasive fungus-induced mucositis conditions.
  • additional treatments can include, without limitation, surgeries and the administration of a second formulation.
  • Surgeries can include, without limitation, the removal of polypoid growths or other tumors, the physical opening of a cavity, and the insertion of catheter tubes and the like.
  • a second formulation can include, without limitation, antifungal agents, mucolytic agents, antibacterial agents, anti-inflammatory agents, immunosuppressants, dilators, vaso-constrictors, decongestants, steroids, anti- cholinergics, leukotriene inhibitors, anti-histamines, therapeutic compounds, and combinations thereof.
  • this second formulation can be administered to a mammal by any route.
  • oral, intraperitoneal, intradermal, intravenous, subcutaneous, intramuscular, topical, intranasal, and intrabronchial administration can be used to deliver a second formulation to a mammal.
  • asthma lung passageways
  • Individuals suffering from asthma can exhibit symptoms such as wheezing, difficulty breathing (particularly exhaling air), dyspnea, and tightness in the chest.
  • Factors that can exacerbate asthma include rapid changes in temperature or humidity, allergies, upper respiratory infections, exercise, stress, and smoking.
  • Individuals suffering from asthma can be identified using any of the known methods in the .art.
  • asthma can be, without limitation, diagnosed objectively with a pulmonary function test (increased airway resistance) with or without provoking the airway (e.g., methacholine challenge test), chest X-rays, and auscultation of the chest.
  • Individuals at risk for developing asthma can include, without limitation, those individuals that have had a previous episode of asthma.
  • elderly individuals individuals having cystic fibrosis, chronic rhinosinusitis with or without gross nasal-paranasal polyps, aspirin sensitivity, or a family history of respiratory problems or allergies; and individuals that are exposed to significant levels of allergens (e.g., fungus spores, pollen, and chemicals) or irritants can be at risk for developing asthma.
  • allergens e.g., fungus spores, pollen, and chemicals
  • Chronic asthmatic individuals can be treated by directly mucoadministering an antifungal agent to at least a portion of the airways in an amount, at a frequency, and for a duration effective to reduce or eliminate asthma symptoms.
  • Such direct mucoadministrations can be simile to the methods and materials described herein for the treatment and prevention of non-invasive fungus- induced rhinosinusitis since the nasal-paranasal cavities are airways.
  • nasal sprays and nasal irrigations can be used to directly mucoadminister antifungal agents to airway mucus.
  • chronic asthmatic individuals can be treated by directly mucoadministering an antifungal agent to at least a portion of the lung airways in an amount, at a frequency, and for a duration effective to reduce or eliminate asthma symptoms.
  • aerosol or powder forms of an antifungal agent can be used for direct mucoadministration to lung airway mucus by inhalation through the mouth or nose.
  • individuals at risk for developing chronic asthma can be prophylactically treated by mucoadministering an antifungal agent to at least a portion of the airways in an amount, at a frequency, and for a duration effective to prevent asthma symptoms.
  • an antifungal agent to at least a portion of the airways in an amount, at a frequency, and for a duration effective to prevent asthma symptoms.
  • prophylactic treatments can be similar to the methods and materials described herein for the prophylactic treatment of non- invasive fungus-induced rhinosinusitis.
  • Example 1 Collecting and analyzing mucus samples The following methods and materials were used to collect and analyze mucus from 202 patients. Prior to collecting the mucus, each patient was directed to inhale and then lower his or her chin toward their chest to minimize or prevent the flow of a collection solution out of the nasal-paranasal passageways via the normal drainage at the back of the throat.
  • the collection solution was either a sterile saline solution or sterile water.
  • each patient was positioned such that the flow of the collection fluid out of the nasal passageways would be minimized or prevented.
  • vasoconstrictor such as phenylephrine hydrochloride (1-2 sprays per nostril) or cocaine (topical liquid or powder; less than four mg per kg of body weight).
  • a vasoconstrictor such as phenylephrine hydrochloride (1-2 sprays per nostril) or cocaine (topical liquid or powder; less than four mg per kg of body weight).
  • An injection device such as a syringe-like device having a tube assembly or blunt curved needle, was then partially placed into one of the patient's nostrils or paranasal anatomy such that the collection solution could be forced through the patient's nasal-paranasal anatomy.
  • about five mL to about 30 mL of a collection solution was then injected into a nostril during a time period of about 0.5 and five seconds.
  • about ten mL to about 20 mL of a collection solution was injected into a nostril during a time period of between about 0.5 and three seconds.
  • each patient blew out or forcefully discharged the collection solution either simultaneously as it was being injected or upon sensing its entry into the nostril.
  • the plates were then incubated at 30°C and read as a routine fungal culture. Growth of individual isolates were observed from about two days to about 35 days. Once fungal growth was observed, the organisms were identified using standard mycology techniques including visual, histological, and immunological techniques.
  • Identified fungal genera and species included many fungal organisms previously isolated from AFS patients, such as Absidia, Aspergillus flavus, Aspergillus fumigatus, Aspergillus glaucus, Aspergillus nidulans, Aspergillus versicolor, Alternaria, Basidiobolus, Bipolaris, Candida albicans, Candida lypolytica, Candida parapsilosis, Cladosporium, Conidiobolus, Cunninahamella, Curvularia, Dreschlera, Exserohilum, Fusarium, Malbranchia, Paecilomvces, Penicillium, Pseudallescheria, Rhizopus, Schizophylum, and Sporothrix.
  • fungal organisms were identified that were not previously identified in mucus samples of patients diagnosed positive for AFS, such as Acremonium, Arachniotus citrinus, Aurobasidioum, Beauveria, Chaetomium, Chryosporium, Epicoccum, Exophilia jeanselmei, Geotrichum, Oidiodendron, Phoma, Pithomyces, Rhinocladiella, Rhodoturula, Sagrahamala, Scolebasidium, Scopulariopsis, Ustilago, Trichoderma, and Zygomycete.
  • liquefied mucus samples collected from two patients were cultured onto IMA plates containing either chloramphenicol or ciprofloxacin.
  • Two dishes (one containing chloramphenicol and one containing ciprofloxacin) for each sample were then incubated at 25°C, 28°C, 30°C, 32°C, 33°C, 35°C, and 37°C.
  • Each plate was visually scored for fungal growth and development every other day over a period from about two days to about 35 days from the time of culturing.
  • the scores for each temperature were averaged, thereby providing an estimate of the optimum temperature for spore germination and subsequent growth or development of fungal organisms.
  • the following procedure was used to determine effective .antifungal agents as well as effective concentrations of antifungal agents such that the fungal organisms isolated from patients can be prevented from growing or killed. Seventeen fungal isolates were collected from eight rhinosinusitis patients and tested for susceptibility against amphotericin B, ketoconazole, and itraconazole.
  • NCCLS National Committee on Clinical Laboratory Standards
  • Table I Fungal organisms isolated from 64 of 66 rhinosinusitis patients studied including 17 amphotericin B, ketoconazole, and itraconazole MIC values for selected isolates from eight rhinosinusitis patients.
  • MIC ⁇ g/mL
  • MIC ⁇ g/mL
  • MIC ⁇ g/mL
  • Geotrichum 5 0.1 0.05 37°C
  • Penicillium 30 0.4 3.13 0.5
  • a total of 25 different fungal species was identified from mucus specimens from these non-invasive fungus-induced rhinosinusitis patients. Sixteen organisms never before described as present coincident with AFS were detected from the 64 mucus samples that exhibited fungal growth. The range was about one to seven fungal organisms per patient with an average of about 2.9 fungal species per patient. Sixty-three percent of the cultures included Alternaria, 47 percent included Penicillium, 33 percent included Cladosporium, 33 percent included Aspergillus, 28 percent included Fusarium, and 20 percent included Candida. In a separate study, twelve control individuals (i.e., persons not having chronic rhinosinusitis) had mucus samples collected and analyzed as described herein.
  • Example 2 Treating and preventing non-invasive fungus-induced rhinosinusitis
  • 125 of the 132 patients had the following criteria: (1) presence of observable disease within the nasal-paranasal anatomy as evidenced by a CT scan, (2) presence of allergic mucus as evidenced by histologic evaluation of a surgical specimen, and (3) presence of fungal organisms within nasal-paranasal mucus as evidenced by the ability to culture fungal organisms from a mucus sample.
  • the 125 non-invasive fungus- induced rhinosinusitis patients were started on an antifungal treatment of about 20 mL of an amphotericin B solution per nostril, two to four times daily for at least three months.
  • the concentration of the amphotericin B solution was about 100 mg per liter of saline or water.
  • a 20 mL bulb was used by the patient to mucoadminister the amphotericin B solution into the patient's nasal-paranasal anatomy. Data were compiled for 53 of the patients who had returned for their three month follow-up analysis.
  • Stage 1 polypoid changes/polyps seen by endoscopy only
  • Stage 2 polyps in the middle meatus
  • Stage 1 good/improved Stage 2: very good/free of symptoms
  • Patient symptom evaluation revealed that 44 of the 53 patients gave themselves a stage 2, three of the 53 gave themselves stage 1, .and six of the 53 gave themselves a stage 0 after treatment.
  • the nine patients giving themselves a stage 1 or 0 were the same nine patients that did not have any response as measured by endoscopic evaluation, five of which were shown to contain fungal organisms resistant to .amphotericin B.
  • several non-responding patients were found not to contain amphotericin B- resistant fungal organisms.
  • several patients had mucus samples collected and analyzed before and after antifungal treatment.
  • the patient was diagnosed with rhinosinusitis in the right paranasal sinuses based on a CT scan and a 10.0 KU/L RAST reading to Alternaria.
  • an amphotericin B solution 100 mg/L
  • the average age of the returning patients was 47 years (range 16-74 years).
  • the patients were using the amphotericin B irrigations for an average duration of about six months (range 1-16 months). Some patients had a nasal surgery as recent as one month while others never had such a surgery. In addition, some patients were using topical and systemic steroid therapy. Further, some patients were using an antibiotic nasal irrigation in addition to the antifungal irrigations.
  • the antibacterial solution contained 80 mg gentamicin per L saline (Wilson's solution). Some patients mixed the antibacterial solution with the antifungal solution and then performed the nasal irrigations while others used each solution separately in a sequential manner.
  • Wilson's solution 80 mg gentamicin/L saline
  • a 64 year old female was diagnosed with non-invasive fungus-induced rhinosinusitis and instructed to perform amphotericin B irrigations twice a day, which was later increased to four times a day.
  • endoscopic evaluation revealed evidence of polypoid changes (endoscopic score 1) and the patient gave himself a symptom score of -1.
  • endoscopic evaluation revealed no evidence of disease (endoscopic score 0) and the patient gave himself a symptom score of +2.
  • a 54 year old male was diagnosed with non-invasive fungus-induced rhinosinusitis and instructed to perform amphotericin B irrigations twice a day.
  • the eosinophil count in all the mucosal biopsies from all the sinuses, except the frontal was diminished ( ⁇ 5%) after antifungal treatment.
  • hypereosinophilia had diminished to normal in all the treated sinus areas.
  • sputum samples from the lung were collected from seven asthma patients. Culture analysis of these samples revealed the presence of fungal organisms in each sample. Specifically, Candida albicans, Penicillium, Fusarium, Scopulariopsis, Cryptococcus, Cladosporium, Aspergillus, Aspergillus fumigatus, Aspergillus nidulans, .and yeast were cultured. The number of different fungal species cultured from each sputum sample ranged from one to five.
  • Example 6 - Itraconazole formulations Itraconazole formulations were made by dissolving itraconazole into polyethylene glycol (PEG) to form an itraconazole stock solution.
  • the itraconazole was obtained from 100 mg itraconazole capsules (Janssen Pharmaceutica, Inc.).
  • PEG 400 was used to dissolve the itraconazole. Once dissolved, the stock solution was filtered to remove any insoluble material. Then, the stock solution was prepared for use by dilution with sterile water.
  • An itraconazole formulation containing a steroid was also made. Specifically, the contents from two PULMICORT 200 ⁇ g inhalers (about 91 ⁇ g of budesonide total) was added to an itraconazole PEG-400 stock solution at 70° C for about 15 minutes. The budesonide was added about 5 minutes after the itraconazole powder was dissolved into the PEG-400. After cooling to room temperature, some precipitation occurred. This insoluble material was removed by filtering the solution through fine filter paper under vacuum. The filter was dried and the captured precipitate was measured (36-40 ⁇ g). Thus, about 54 to 50 ⁇ g of steroid remained in the solution/fine suspension.
  • Example 7 Treating and preventing non-invasive fungus-induced rhinosinusitis using itraconazole Three non-invasive fungus-induced rhinosinusitis patients (33 year old male, 70 year male, and 57 year old female) were instructed to perform nasal irrigation with an itraconazole solution.
  • the itraconazole solution contained about 100 mg of itraconazole per L of solution (10% PEG-400 in sterile water) and was prepared as described herein.
  • Two patients were instructed to perform itraconazole irrigations because they did not respond to amphotericin B irrigations. Each patient reported marked improvement in symptoms within two weeks of starting the itraconazole irrigations (symptom scores: -1 to +2 and -1 to +1).
  • the third patient was instructed to perform itraconazole irrigations because of an adverse local reaction to amphotericin B (burning sensation). After treatment with itraconazole, that patient reported symptom improvement (symptom score: from -1 to 0). In addition, that patient did not have any adverse local reaction or problems with the itraconazole irrigations.
  • Example 8 Treating and preventing chronic asthma symptoms using itraconazole
  • the patient was started on an antifungal treatment of about 20 mL of an itraconazole solution per nostril, two times daily.
  • the concentration of the itraconazole solution was about 100 mg per liter.
  • the patient took his last course of systemic steroids.
  • the patient also stopped using the topical steroids as well as the bronchodilator. Since stopping all steroid therapy, the patient's symptoms improved dramatically. Specifically, the patient reports no episodes of shortness of breath and no wheezing during the four to five month period since stopping all steroid therapy.
  • the forced vital capacity (FVC) of the lung improved from 3.99 liter before treatment to 4.80 liter after treatment, an increase of 20.30%; the forced expiratory volume in 1 second (FEVl), a marker for the degree of lower airway resistance, improved from 3.34 liter before treatment to 4.27 liter after treatment, an increase of 27.84%; the maximal forced expiratory flow (FEFmax) improved from 9.1 liter per second before treatment to 12.6 liter per second after treatment, an increase of 38.46%; and the maximum voluntary ventilation (MVV) improved from 119 liter per minute before treatment to 156 liter per minute after treatment, an improve of 31.90%.
  • FVC forced vital capacity
  • the objective markers revealed an improvement of the pulmonary function between 20.3%) and 38.46%, despite no medical therapy other than the antifungal nasal irrigations during the previous four to five months.
  • the itraconazole powder was an authentic substance "AS" (Janssen Pharmaceutica, Inc.).
  • the inhaler was a Pulmicort 200 ⁇ g TURBOHALER® manufactured by ASTRA pharmaceuticals.
  • This inhaled was designed for metered doses of budesonide inhalation powder, but was adapted to administer itraconazole.
  • the patient has been asymptomatic for four weeks, and continues to use the itraconazole powdered treatment.
  • the patient also had at least one nasal polyp initially. That polyp was noticeably reduced in viability by the second week of treatment.
  • Another asthma patient also was instructed to inhale about 200 ⁇ g of pure itraconazole per day using an adapted Pulmicort 200 ⁇ g TURBOHALER®. After about 2 weeks, the patient's condition was markedly improved. The patient remains on the treatment.
  • An asthma patient having non-invasive fungus-induced rhinosinusitis was treated with itraconazole using a nebulizer. Specifically, about two mL of an itraconazole solution (about 10 mg itraconazole per mL PEG-400) was applied per day in a nebulizer.
  • the nebulizer was an air pressurized PULMO-MATE brand manufactured by DeVillbis. After about two weeks, the patient demonstrated improvement in both asthma and non-invasive fungus-induced rhinosinusitis conditions as evidenced by an overall improvement of symptom scores. Improvements were also noted in one week increments.
  • Example 9 Identifying non-invasive fungus-induced otitis media
  • Mucus samples from the middle ear were collected using a suction trap from three patients diagnosed with chronic otitis media. Culture analysis of the samples revealed the presence of fungal organisms. Specifically, the mucus sample from the first patient was positive for Candida and Trichophyton rubrum species, the mucus sample from the second patient was positive for Penicillium species, and the mucus sample from the third patient was positive for Aspergillus species. In addition, microscopic examination revealed a large number of degenerating eosinophils within each mucus sample. Thus, these results indicate that chronic otitis media is most likely caused by non-invasive fungal organisms. Moreover, it appears that chronic otitis media is a non-invasive fungus-induced mucositis that can be treated and prevented using the antifungal treatment and prevention approaches described herein.
  • Example 10 Treating non-invasive fungus-induced intestinal mucositis Three out of five consecutive patients with chronic rhinosinusitis reported having a history of colitis. Two patients were started on an antifungal treatment of one capsule of itraconazole (provided by Janssen Pharmaceutica, Inc.) per day. The capsule contained 100 mg of itraconazole. Each patient was instructed to take the capsule before bedtime a minimum of two hours after their last meal and without any cola. Food and cola beverages increase absorption of the drug. When taken as described, about 50 percent of the itraconazole should remain in the bowel lumen for treatment of non-invasive fungus-induced intestinal mucositis symptoms.

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PCT/US1998/022403 1997-10-22 1998-10-22 Use of antigunal agents for the topial treatment of fungus-induced mucositis WO1999020261A2 (en)

Priority Applications (20)

Application Number Priority Date Filing Date Title
APAP/P/2000/001805A AP2000001805A0 (en) 1997-10-22 1998-10-22 Use of antifungal agents for the topical treatment of fungus-induced mucositis.
HU0004170A HUP0004170A3 (en) 1997-10-22 1998-10-22 Methods and materials for treating and preventing inflammation ofmucosal tissue
ES98955065T ES2292210T3 (es) 1997-10-22 1998-10-22 Uso de agentes antifungicos para el tratamiento topico de mucositis inducida por hongos.
AU11959/99A AU1195999A (en) 1997-10-22 1998-10-22 Methods and materials for treating and preventing inflammation of mucosal tissue
IL13577498A IL135774A0 (en) 1997-10-22 1998-10-22 Use of antinfungal agents for the topical treatment of fungus-induced mucositis
JP2000516659A JP2001520188A (ja) 1997-10-22 1998-10-22 粘膜組織の炎症を治療および予防するための方法ならびに物質
EP98955065A EP1024814B1 (en) 1997-10-22 1998-10-22 Use of antifungal agents for the topical treatment of fungus-induced mucositis
SK573-2000A SK5732000A3 (en) 1997-10-22 1998-10-22 The use of an antifungal agent to reduce or eliminate non-invasive fungus induced rhinosinusitis, a pharmaceutical compostion, an antifungal formulation and industrial product comprising the same
CA2308201A CA2308201C (en) 1997-10-22 1998-10-22 Use of anti-fungal agents for the treatment of fungus-induced mucositis
KR1020007004368A KR20010031363A (ko) 1997-10-22 1998-10-22 진균류에 의한 점막염을 국소 치료하기 위한 항진균제의용도
DE69838338T DE69838338T2 (de) 1997-10-22 1998-10-22 Verwendung von antimykotica zur topischen behandlung von pilz-induzierten schleimhautentzündungen
EEP200000253A EE200000253A (et) 1997-10-22 1998-10-22 Seentevastase toimeaine kasutamine ravimite valmistamiseks, mis on ette nähtud mitteinvasiivsetest seenorganismidest tingitud haiguste raviks või vältimiseks
BR9814615-7A BR9814615A (pt) 1997-10-22 1998-10-22 Métodos e materiais para o tratamento e prevenção de inflamação do tecido da mucosa
EA200000439A EA200000439A1 (ru) 1997-10-22 1998-10-22 Способы и материалы для лечения и профилактики воспаления ткани слизистой оболочки
DK98955065T DK1024814T3 (da) 1997-10-22 1998-10-22 Anvendelse af antisvampemidler til topisk behandling af svampe-induceret mucositis
IS5463A IS5463A (is) 1997-10-22 2000-04-19 Notkun mótefna gegn sveppum við staðbundna meðferð á slímbólgu af völdum sveppa
IL135774A IL135774A (en) 1997-10-22 2000-04-19 Use of fungicides to prepare drugs for topical treatment of fungal diseases caused by fungi
NO20002069A NO325714B1 (no) 1997-10-22 2000-04-19 Anvendelse av antisoppmiddel for fremstilling av et medikament for behandling av soppindusert rhinosinusitt.
BG104371A BG104371A (en) 1997-10-22 2000-04-24 The use of antimycotic forms for local treatment of fungi-caused mucosite
HK01100853A HK1029935A1 (en) 1997-10-22 2001-02-06 Use of antifungal agents for the topical treatmentof fungus-induced mucositis

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US6270997P 1997-10-22 1997-10-22
US60/062,709 1997-10-22
US6341497P 1997-10-28 1997-10-28
US6341897P 1997-10-28 1997-10-28
US60/063,418 1997-10-28
US60/063,414 1997-10-28
US8327298P 1998-04-28 1998-04-28
US60/083,272 1998-04-28
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